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Welcome and Thank You for Joining Us Today!

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Title: Changes in Physical Therapy Documentation Author: Nita Barchus, P.T. Last modified by: Kate Ericksen Created Date: 4/17/2012 8:43:43 PM Document presentation ... – PowerPoint PPT presentation

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Title: Welcome and Thank You for Joining Us Today!


1
Welcome and Thank You for Joining Us Today!
  • Some reminders about the functions of todays
    phone/webcast presentation
  • This is a RECORDED PRESENTATION of the Changes
    in Physical Therapy Documentation webcast with
    Nita Barchus, P.T. For the phone bridge, there
    are functions available to ALL callers
  • On your phone, press 2 to raise your hand to ask
    a question
  • The phone bridge is in QA Mode - All guests are
    muted (guests MUST press 7 to talk)
  • The text chat room will be disabled during the
    LIVE Q A session. You are encouraged to submit
    your text questions using the link on the webcast
    page in the upper left corner.
  • During the live Q A session we are assuming
    that all callers have completed listening to the
    recorded webcast. You are welcome to email Nita
    directly with your comments, suggestions for
    future sessions and questions at
    nita.megassociates_at_gmail.com
  • Copies of todays slides are available to
    download directly from the link provided on the
    webcast page.
  • PLEASE TAKE THE TEST BEFORE THE SURVEY AND WAIT
    UNTIL THE END OF THE PRESENTATION!

2
Changes in Physical Therapy Documentation
  • Nita Barchus, P.T.
  • MEG Associates Consulting Group, Inc.

3
Changes in Physical Therapy Documentation
  • OBJECTIVES
  • Explain the essential components of therapy
    documentation for reimbursement
  • State what to include in reassessments
  • Demonstrate how to document for a nurse reviewer
    if you are a therapist
  • Perform an appropriate therapy documentation
    review if you are a nurse

4
Changes in Physical Therapy Documentation
  • OUTLINE
  • Essential components for reimbursement
  • OASIS
  • Therapy Evaluation
  • Revisit Notes
  • Reassessments
  • DC Summary
  • How to review therapy documentation if you are a
    nurse
  • Q and A

5
  • Essential Components for
  • Reimbursement

6
Essential Components for Reimbursement
  • The Basic Requirement has not changed
  • Treatment must be Reasonable, Necessary, and
    Require the Skills of a Therapist

7
Essential Components for Reimbursement
  • How does Medicare determine whether therapy
    treatment is reasonable and necessary?

8
Essential Components for Reimbursement
  • OASIS
  • The Start of Care OASIS is the place to begin
    documenting that therapy treatment is reasonable
    and necessary
  • This is the first information Medicare receives
    from your agency about the patient
  • Whether completed by a nurse or a therapist it
    must show that therapy is reasonable and
    necessary

9
Essential Components for Reimbursement
  • OASIS
  • M1020 Diagnoses
  • List must include one or more diagnoses to
    explain why the patient is receiving therapy
  • M1800s ADLs and IADLs
  • Should indicate that assistance is required if
    the patient is independent in all, then he/she
    probably does not need therapy

10
Essential Components for Reimbursement
  • OASIS
  • M1800s (contd)
  • Answers must be consistent with the therapist(s)
    evaluations - Interdisciplinary communication
    will be required between the nurse and therapists
  • There is often a discrepancy between the
    nurses answer to M1860 Ambulation/Locomotion
    and the physical therapists evaluation

11
Essential Components for Reimbursement
  • OASIS
  • (M1860) Ambulation/Locomotion Current ability
    to walk safely, once in a standing position, or
    use a wheelchair, once in a seated position, on a
    variety of surfaces.
  • 0 Able to independently walk on even and
    uneven surfaces and negotiate stairs with or
    without railings (i.e., needs no human assistance
    or assistive device).
  • 1 With the use of a one-handed device (e.g.
    cane, single crutch, hemi-walker), able to
    independently walk on even and uneven surfaces
    and negotiate stairs with or without railings.
  • 2 Requires use of a two-handed device (e.g.
    walker or crutches) to walk alone on a level
    surface and/or requires human supervision or
    assistance to negotiate stairs or steps or uneven
    surfaces.
  • 3 Able to walk only with the supervision or
    assistance of another person at all times.
  • 4 Chairfast, unable to ambulate but is able
    to wheel self independently.
  • 5 Chairfast, unable to ambulate and is unable
    to wheel self.
  • 6 Bedfast, unable to ambulate or be up in a
    chair.

12
Essential Components for Reimbursement
  • OASIS
  • M1900s Prior Level of Function ADL/IADL and Fall
    Risk
  • If PLOF was dependent with ADLs and IADLs, the
    therapist(s) must be careful to set realistic
    goals, and must include caregiver training

13
  • Essential Components for Reimbursement
  • Therapy Evaluation

14
Essential Components for Reimbursement
  • Therapy Evaluation
  • Must document functional limitations (such as
    assistance required/ safety concerns with bed
    mobility, transfers, gait, stairs, dressing
    tasks, making needs known, swallow)
  • Remember This will be reviewed by a nurse so
    functional limitations, treatment plan, goals
    must all be to written so that it is apparent to
    a nurse that PT/ OT/ ST is reasonable and
    necessary

15
Essential Components for Reimbursement
  • Therapy Evaluation
  • Must list functional goals
  • Examples
  • The patient will transfer from the bed to the BSC
    with SBA in 2 weeks
  • The patients balance will improve to low fall
    risk, as evidenced by an improvement in the
    Tinnetti score to gt24 points
  • The patient will perform upper body dressing with
    min assist

16
Essential Components for Reimbursement
  • Therapy Evaluation
  • Plan of care
  • It is often appropriate to frontload visits to
    address the home environment in terms of fall
    risk factors, medical equipment needs, patient
    and family education and training for safety

17
  • Essential Components for Reimbursement
  • Revisit Notes

18
Essential Components for Reimbursement
  • Revisit Notes
  • This is where skilled care is documented
  • Every note must indicate that skilled care was
    provided, or the visit is not billable
  • -Treatment plan should be adjusted every visit
  • -Any set-back should be explained
  • -Treatment should address functional
    limitations, not only therapeutic exercise
  • -Training should be documented for gait and
    transfers

19
Essential Components for Reimbursement
  • Revisit Notes
  • Steady progress toward functional goals must be
    documented
  • Interdisciplinary communication should be
    documented

20
  • Essential Components for Reimbursement
  • Therapy Reassessments

21
Essential Components for Reimbursement
  • Therapy Reassessments
  • Reassessments are required at the 13th visit, the
    19th visit, and at least every 30 days. (If more
    than one therapy discipline is seeing the
    patient, each must reassess close to and before
    the 13th and 19th visits)
  • The purpose of reassessments is to justify
    continued billing!

22
Essential Components for Reimbursement
  • Therapy Reassessments
  • Medicare says each therapy discipline must
    functionally reassess the patient and compare
    the resultant measurement to prior measurements
  • Re-stating the functional goals and addressing
    progress, or lack of progress, toward each
    satisfies the requirement
  • Objective measurements may or may not be
    functional

23
Essential Components for Reimbursement
  • Therapy Reassessments
  • Examples
  • The patient will transfer from the bed to the BSC
    with SBA in 2 weeks Good progress pt now
    requires min assist.
  • The patients balance will improve to low fall
    risk, as evidenced by an improvement in the
    Tinnetti score to gt24 points Good progress
    Tinnetti score at initial eval was 16/28
    indicating high fall risk current score is 21/28
    indicating moderate fall risk.
  • The patient will perform upper body dressing with
    min assist Goal met

24
Essential Components for Reimbursement
  • Therapy Reassessments
  • If the measurements do not indicate progress
    toward the goals, and/or do not indicate that
    therapy is effective, but the therapy continues,
    the therapist must document why the physician and
    therapist have determined that therapy should be
    continued.

25
  • Essential Components for Reimbursement
  • Discharge summary

26
Essential Components for Reimbursement
  • Discharge Summary
  • Because it often lays right on top of the PT/ OT/
    ST section of the chart (if records are filed in
    reverse chronological order), it is the first
    thing an auditor will see when reviewing therapy
    records it can be a very useful document in
    proving that treatment was reasonable and
    necessary!
  • If goals are not re-stated and progress addressed
    in the DC summary, it is probably not being used
    to best advantage.

27
  • Reviewing Therapy Documentation if You Are a
    Nurse

28
Reviewing Therapy Documentation if You Are a Nurse
  • OASIS guidelines are the same, no matter who is
    filling it out
  • Therapy Evaluation must have clear functional
    goals
  • Therapist(s) should be in right away if there are
    safety concerns such as fall risk impaired
    mobility contributing to pressure ulcer risk or
    to incontinence etc

29
Reviewing Therapy Documentation if You Are a Nurse
  • Therapy Revisit Notes must indicate steady
    progress is being made toward the functional
    goals
  • Skilled care must be evident at every visit
  • Handwriting must be legible
  • If these things are not apparent to you, chances
    are good they will not be apparent to the nurse
    who is auditing the chart for Medicare!

30
Reviewing Therapy Documentation if You Are a Nurse
  • Therapy Reassessments must restate goals from the
    initial evaluation and document what progress has
    been made toward those goals Medicare requires
    a functional comparison between timepoints be
    made by the therapist

31
Reviewing Therapy Documentation if You Are a Nurse
  • The Discharge Summary should also restate goals
    and indicate which were met, and for goals that
    were not met, an explanation should be given

32
Now we will have an OPEN QA
  • Q and A

33
Thank You for Joining Us Today!
  • Your feedback is welcome and encouraged!
  • Copies of todays slides are available to
    download directly from the link provided! OR by
    going here http//meg.mykate.com/index.html and
    click the DOWNLOAD button
  • AFTER YOU HAVE COMPLETED THE PRESENTATION
  • PLEASE TAKE THE TEST BEFORE THE SURVEY
  • If you have any problems or are not able to
    listen to the entire RECORDED webcast, the
    recording will be available at the SAME LINK
    included in your invitation email from June 15th
    through June 30th .
  • If you have further questions you can email Nita
    at
  • nita.megassociates_at_gmail.com
  • Email us with comments or suggestions for our
    moderator at dezignsbykate_at_gmail.com
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